Family and Couples Therapy

Question 1

General characteristics of family and couples therapy

Answer 1

Problems are seen as lying in the interaction of individuals/families, rather than in the individuals

Often manifests as one person having a problem ‘the patient’

Therapists have to avoid making the same assumption that it is about the individual

Commonly delivered by a team (one observing and guiding the therapist in the room)

Question 2

How distinct are the different approaches to family and couples therapy?

Answer 2

The models sometimes overlap (particularly structural and strategic)

Work of Haley started as strategic work and moved to being structural

Therapists who devise the therapies are people and can end up rowing about trivial things (the systemic group broke in two - there are a lot of therapies out there and some of them look very similar)

Question 3

Where can family and couples therapy be applied?

Answer 3

Families
Couples
Therapeutic settings
Workplaces

Most common in family therapy where the child is the ‘patient’ and in marriage counselling

Question 4

Strategic approaches

Answer 4

Derived from Bateson’s (1956) concepts of how family systems become problematic (particular focus on circularity)

Based on the assumption that family problems emerge when the family tries to solve issues, but the solutions are faulty - communication becomes contradictory (words and expression do not agree)

So the family solutions become factors that maintain or worsen difficulties

Question 5

Role of therapist in strategic approaches

Answer 5

Strategic therapists do not join the family - more external and prescriptive

Adopts a position of being active and directive

Plan is to break up the pathological interaction patterns (symptom removal as the family will develop more adaptively once the symptoms are alleviated

Not cosmetic surface-level changes

Aim for more fundamental, rule-level changes

Question 6

Strategies in strategic approaches

Answer 6

Commenting on how people in the system deal with each other so that patterns become overt (you all talk at once but do not listen)

Disrupting interactive sequences that can lead to conflict (one person talks at a time instead of all talking across each other)

Reorganise the system to function differently (the family must eat one meal a day together)

Breaking repetitive negative cycles (stop going out for a drink when frustrated with your partner)

Question 7

Structural approaches

Answer 7

Based on the assumption that family problems emerge when boundaries between members and their roles are not clear or appropriate

Question 8

What do you tend to see when boundaries between members of a family are not clear

Answer 8

Hierarchical problems (grandparents overrule parents; children expected to take on adult roles)

Cross-generational alliances (mother and grandmother act as parents, excluding the father)

Question 9

Pathological patterns in structural approaches

Answer 9

Enmeshment

Disengagement

Question 10

Enmeshment

Answer 10

Boundaries between family members are unclear/diffuse

Question 11

Disengagement

Answer 11

Boundaries are too rigid

Question 12

What are structural approaches based on?

Answer 12

Most developed from Minuchin’s (1978) work on psychosomatic families
- Family issues driving and maintaining the development of problems with a physical element (e.g. asthma, anorexia nervosa)

Pathology lies within the family, not the individual (family structure tends to react against any effort by the ‘patient’ to become less ill

Question 13

Aims of structural approaches

Answer 13

To create change by ‘getting into’ the family system and interrupting patterns

‘Joining’ the family in therapy

Question 14

Treatment aims of structural therapy

Answer 14

Achieve a pattern of clear, appropriately flexibly boundaries between the parental subsystem, the child subsystem, and the world

Helping families reorganise so that

• Parents are in charge
• Boundaries are clear and flexible
• There are healthy patterns of interaction

Allows for growth in the individual and development in relationships (children’s roles change as they mature)

Question 15

Therapy techniques in structural approaches

Answer 15

Getting the family to enact their intentions, rather than just describing them, to highlight the way those interactions cause problems

Breaking up patterns of interaction by siding with one family member and developing their power within the family

Increasing stress within the family to unbalance the system

Manipulating mood states by acting out family mood displays

Labelling, exaggerating or prescribing symptoms (showing the family what they are doing)

Aims to allow slow changes, rather than sudden leaps (slower compared to strategic therapy)

Question 16

Systemic approaches

Answer 16

Based on the assumption that family problems emerge when the family makes errors of judgement about causality and truth

Palazzoli (1978) - based on the assumption that one cannot make people change but one can make the system unstable, so that it has to find a new way of resting to a stable point

Assumed that the new stable point will be less pathological and more open to change than the former one (cannot be any worse)

Question 17

What do you tend to see in systemic approaches

Answer 17

Belief that ‘I am right; you are wrong’

Failure to recognise that our own actions have consequences that cause us problems

Action on the basis of unilateral control (‘I am in charge, and you do what I say’)

Question 18

Therapist’s role in systemic therapy

Answer 18

Be neutral - no prescribing a better way of being, assume that the family will have a strong capacity to self-heal without being told how

Develop hypotheses about what is going wrong in the family system

Use circular questioning to get the family members to discuss their own perspective about what is happening in the family system

• What do they think others believe is happening?
• Provokes discussion within the family, to correct misconceptions

Question 19

Techniques in systemic therapy

Answer 19

Prescribing change in everyday life (not concerned about whether homework is done, as the aim is to get the family to be aware of their interactive style)

Prescribing paradoxical work

• ‘As the family is clearly held together by your daughter being unhappy, we want the parents to carry on being as negative to everyone as possible, and the daughter to be as miserable as she can, as that is the best way that you all know how to function as a family’
• Makes the family aware of their style, and its impact

Question 20

Heatherington et al. (2015)

Answer 20

Summarises the evidence regarding which of the approaches have strong, modest and weak evidence

Points out that some have almost no evidence

Question 21

The missing evidence

Answer 21

Evidence tends to be patchy

Does a therapy that was developed for one disorder work for another?

Is the therapy delivered as a stand-alone treatment or as a module of a broader therapeutic programme

Moderators and mechanisms

• Who benefits?
• How does it work?

Question 22

Current developments in family and couples therapy

Answer 22

Greater emphasis on behavioural approaches

Behavioural Couples Therapy

Family-Based Treatment for bulimia nervosa

Question 23

Behavioural Couples Therapy

Answer 23

Particularly effective when one member of the couple is depressed
As effective as CBT (Bodenmann et al., 2008)

Question 24

Family-Based Treatment for bulimia nervosa

Answer 24

More effective than CBT

- Le Grange et al. (2015)

Question 25

Future developments

Answer 25

Pin down therapies

Understand the mechanisms